Resources on getting faster?

[TooMuchResearch]

Or more specifically, increasing PPH?

I've dug through our data and I am in the bottom third at best in terms of PPH. My level 5 charts and CC billing are above group average but overall RVU/hour is average to slightly Below. Now, perhaps I'm just intentionally picking complicated and sick people, but I doubt it. Or my partners are cherry picking all day every day and I just haven't noticed.

So, who can point me to good resources for how to pick up the pace?

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[Zebra Hunter]

I’m not sure how “resources” are going to help you pick up the pace. It’s going to be totally dependent on your job. If it bothers you that much and are serious about improving your PPH, pay attention to your colleagues that are near the top. Watch closely at what they do when they are at their computers or see how long they typically spend with patients. Pay attention to how and when they chart. Also, outright just ask what they do. How often are they checking the board for new patients? People who are near the bottom in PPH in my group tend to be the people that are completely oblivious to the number of people checking in, or in some cases, don’t care. Also, much like in a restaurant kitchen, if you want to pick up the pace, you need to maintain a “sense of urgency”.

In terms of PPH, I’m probably among the top in my group. I am constantly checking the board. I don’t wait to finish notes or HPIs before picking up new patients. My chart reviews are efficient and just look at discharge summaries and last ED visit. I rarely spend more than 5 minutes in a patient room at a time unless absolutely necessary. I discharge patients immediately without workups if I don’t think it’s necessary which means limiting the number of times I need to speak to these patients. For patients I expect for labs/imaging to be normal that are getting workups done, I discuss with them on initial interview my suspicions on diagnosis and that their workup will likely be negative. I tell them if anything comes up positive/abnormal, I’ll talk to them again, otherwise just let the discharging nurse know if they have a question for me (which typically frees up 5 minutes every time I do this, which can be 10x a shift some days).

At the beginning of shifts at locations where we have staggered shifts when the waiting room is sometimes 30-40 deep with patients that haven’t been picked up, I focus my energy on the ones that can be immediately dispo’d (labs/imaging already back, or CCs like “dental pain”, “back pain”, “flu-like illness”) and the ones most likely to be emergencies (those with VS abnormalities, elderly with abdominal pain, etc.). Once those are seen, I then tackle the younger abdominal pains and older chest pains and everyone else still waiting to be seen. Then towards the end of my shift, I focus on quick dispos rather than picking up patients I will inevitably have to hand off like chest pain, abdominal pain, or likely psych admits.

 

[medninja]

I struggled with this a lot after residency and found an approach that’s not intuitive but mostly works.

Don’t ape the fastest people. They’re likely cut from a different cloth. The absolute fastest ED docs test very little, are ultra decisive and suffer little or no decision fatigue. That is, the fact they had a tough patient doesn’t bog them down for the rest of the shift. I’m just not like this.

I was my slowest when I tried to test less. Talking to patients is where most of my time was spent (lost) and the source of my frustrations. They just aren’t going to give you reliable information. The PE is likewise mostly there to suggest studies to order. Neuro and Abd exams aside, the physical is just not a good test. If you have a doubt, order an objective test. Send lots of them and do it up front. Then ignore the patient until everything is back and dispo them based on the objective results.

This approach allows you to juggle lots of patients at once because at any point in time, you’re ignoring most of them. You’re also in a one up position with disgruntled patients who still want to know why their poo is green or what virus they’re non-sick kid has. You can point to the CT and say they’re fine and you can tell the cloying mom that it’s parainfluenza 4. It also makes admits easier because you don’t have to call the next hospitalist on shift because the first demanded a procalcitonin — that bs was sent along with a lactate, BNP, BCx and a pelvic US of their wrist.

Essentially, you use your radiologist, US tech and lab staff to maximal effect, helping you to definitively rule out things on your differential as you burn through patients.

I found by doing this, I also could stream line my notes. The medical decision making is essentially, “I thought about it and ruled it out.” For the few things you don’t fully rule out, you have the mental bandwidth to make an argument on the preponderance of the evidence. You can note that they’ve been seen for X for months, appendicitis rarely presents as chronic abdominal pain, they take too many pain pills and always seem to be positive for meth.

There’s a few caveats. Always, be willing to add another study or go the extra mile to revisit your physical so you don’t miss stuff. Also, you’ll get faster doing this, but never be the fastest. There’s no substitute for just not sending the dimer and being cool with it.

 

[xaelia]

I was my slowest when I tried to test less. Talking to patients is where most of my time was spent (lost) and the source of my frustrations. They just aren’t going to give you reliable information. The PE is likewise mostly there to suggest studies to order. Neuro and Abd exams aside, the physical is just not a good test. If you have a doubt, order an objective test. Send lots of them and do it up front. Then ignore the patient until everything is back and dispo them based on the objective results.

This approach allows you to juggle lots of patients at once because at any point in time, you’re ignoring most of them. You’re also in a one up position with disgruntled patients who still want to know why their poo is green or what virus they’re non-sick kid has. You can point to the CT and say they’re fine and you can tell the cloying mom that it’s parainfluenza 4. It also makes admits easier because you don’t have to call the next hospitalist on shift because the first demanded a procalcitonin — that bs was sent along with a lactate, BNP, BCx and a pelvic US of their wrist.

Aww yiss the shotgun that fires radioactive bullets.

 

[Arcan57]

The secret to increasing your pph is to pick up more patients. The docs that rank below the top 2 tend to be very similar in workup style and efficiency as the docs that are just above the bottom 2 in terms of pph. The main difference is that the top quartile docs prioritize picking up new patients above completely finishing up the available work with their prior existing patients. If you habitually sign up for a new patient every time you sit down to start charting on the patient you just saw, that's going to be an extra 4 or so patients per 8 hr shift. The docs in your group may also have a higher threshold for number of active patients before they start tapping out on taking new patients. If they're comfortable with 10-12 active patients and you're comfortable with 7-8, that's going to be a pretty big difference in pph over the course of a busy shift. Generally people come out of residency pretty hardwired in their number of active patients comfort zone. Changing it usually involves figuring out which concerns can be offloaded to a peripheral brain (post-it notes, scribes, tracking board notes) and anticipating what the nurses are going to need so you're not constantly being interrupted with quality of life questions (can they eat, they want tylenol, they're nauseated, they need a work note, etc).

Finally, picking off people that need NO WORKUP can make a huge difference in pph. You can cycle through 3 snotty kids in the time it takes to get one COVID/flu/RSV swab back.

 

[miacomet]

As a fast doc all I can say is slow doc wins...unless you are getting paid solely on productivity, seeing fewer patients is easier for you snd you have less liability. One reason I quit my last job is that being fast isn't compensated or appreciated most places. Patients don't care, admin doesn't care, your colleagues appreciate it but that's not very important.

Stay slow and be happy.

 

[JacobMcCandles]

Several things:

1.) ABC&D: Always Be Charting & Dispoing
2.) Find the rate limiting step for each patient that will lead to a disposition and make sure it gets done quickly.
3.) Picking up the sick and complicated patients are honestly sometimes the easiest patients as you already know their disposition (admission).
4.) Put all your orders in correctly at the beginning. Don't get some labs, get the results, get some more labs, then order some imaging, etc.

 

[Groove]

Or more specifically, increasing PPH?

I've dug through our data and I am in the bottom third at best in terms of PPH. My level 5 charts and CC billing are above group average but overall RVU/hour is average to slightly Below. Now, perhaps I'm just intentionally picking complicated and sick people, but I doubt it. Or my partners are cherry picking all day every day and I just haven't noticed.

So, who can point me to good resources for how to pick up the pace?

Sorry for the length!

I'm in a group that covers 3-4 different hospitals and am routinely the fastest doc in the group each month based on metrics. I'm not entirely sure if I have the most PPH but it's probably close. My LOS and TAT are what is the fastest. (Keep in mind, c-suite is very interested in ED and Provider specific metrics but many times they want their cake and to eat it too. Meaning....they want fast LOS, low LWATs, fast TATs but they also want maximized RVU and you simply can't have both. For instance, I'm definitely the fastest but in no way do I generate the most RVU, that's going to be a medium speed maximalist. So, I'll see what I can add from my perspective. This is all coming from a doc who was very much a maximalist coming out of residency and throughout my career as I've gained more experience, seen more pathology, picked up tips and tricks along the way....I've become very much a minimalist. For me that was a process but I've noticed that some people graduate residency and are very much a minimalist right from the start. It really just depends on the person, I think.

So, we all know as soon as you come out the pt room, you know their disposition. Now it's simply a matter of deconstructing whatever obstacles stand in your way to disposition the pt. That is going to depend on your hospital, your ED flow, your hospitalist group, hospital/ED culture, how quick lab and XR can turnover, hospital admin, and your individual comfort level.

Choose your patients wisely. I'm not saying cherry pick but I've got some colleagues that go bonkers over peri-arrest semi-codes that dump into the ER. Most of them are young and not too far out of residency looking to tube and line somebody. I'm perfectly fine and efficient in seeing these sick patients but if someone else wants to have them, more power to them. At this point in my career I've more than seen my share. Most of the time these cases are going to significantly eat up your cognition and prevent you from seeing other patients. They are also the highest liability cases you will see for the entire shift. Why sprint to these rooms if you have other docs that are all gung ho and want to take them? Let them take them unless you really need the experience or you have a resident that you need to teach. If you're single coverage then you don't have much of a choice.

Do all these patients need labs? Seriously. If they are eating/drinking/voiding/stooling normally and reporting no decrease in urination, do they really need a metabolic work up? I could argue that they don't simply based on the above. I don't ever get labs if I can help it. Do they need that 2nd and 3rd troponin on your chest wall syndrome pt before you can d/c? Probably not. Does your gentleman who came in for acute urinary obstruction and hasn't been able to pee for a day really need a BMP? He feels fantastic after placement of the foley and tells me he was urinating just fine up until yesterday. Even if he has a mild AKI, it's going to resolve. Why lab him up? Discharge him to f/u with urology. Does the viral URI pt need all their strep/flu/covid testing to be resulted before they can be discharged? They have the EMR portal on their phones. Have them check it at home and the only thing it would change in management is the need for quarantine, etc.. Does your nursing home patient coming in for an accidental fall where they bumped their head even need labs? Does your nursing home pt coming in for PEG tube change even need an XR? And even if you get the gastrograffin XR, do you even need the radiologist to read it befog you d/c them back home? Of course not.

Does every peritonsillar abscess need a CT? Man, after you've seen enough of these, I can tell you exactly which ones are less than 2cm or over 2cm and which ones indicate the need for aspiration. I have no problem documenting that there is likely a developing tonsillar phlegmon but it is not large enough for drainage based on my clinical exam. No high risk features on exam. Put them on clinda/steroids and refer to ENT for f/u in 3 days. They absolutely do not need a CT with labs along with an 2 hour wait only for you to get back a 0.6cm abscess and your expected 12K WBC. Not to mention it took radiology 45 mins to convince the nurse to get an HCG before they would take her back for the imaging and now you've changed nothing about your disposition other than to ensure the pt is going to get triple their ER bill.

Don't fear the waiting room. Stop sitting in a chair and being lazy. Take a COW/WOW out there and start dumping in MSE orders or pulling people into cubby's to get a brief history or exam. When our ED is gridlocked, I immediately go out to the waiting room and see people in this manner. I don't like the WR piling up and any time it gets over 20 is just a recipe for a bad outcome. I decompress as much as possible. All those URIs probably need zero testing. I'll see 3 at a time and then go print off all their stuff. If they want flu/covid/strep then I have the nurses swab them and I tell them it's not going to change my plan and to check the results at home. Call it "acute URI" so none of your MIPS get dinged. Keep churning through WR patients. Occasionally, I'll get some old geezer sent over for admission and he's got fresh labs from today at his oncologist office and I can admit immediately. I have very few colleagues that are willing to work the WR like I do and that may be why some of my numbers look so good in honesty.

At the end of your shift, stop grabbing sick people 1.5 hours before shift end. Finish your notes. While your charting, drop in MSE orders for new patients if the chief complaint or triage note makes sense. If you get done early with your charts, get up and MSE the pt's in a room and then go back out to WR and find a handful more easy discharges that need minimal testing. Chart them real quick and your done with your shift. If you're doing all that each and every shift, there's no way your metrics aren't going to shine and as much as I hate saying it...good metrics are good for your job security. If you're going to play the bell curve game, get lost somewhere in the middle and try not to be an outlier.

From a liability standpoint, remember...it's difficult to fault you for not getting a test that wasn't indicated in the first place and it's almost impossible to prove that an abnormal result was present during a single encounter when you didn't test for it. I'm not saying to be unsafe with patients, I'm just saying that sometimes over ordering gets you into more trouble than under ordering.

 

[Rekt]

I was the fastest resident. I've been the fastest doc at all the places I've worked so far and at current shop I'm fastest again. With that said I agree with miacomet. I envy the slow docs that don't give a **** about anything seeing barely one pph. If admin isn't bothering you and you're not RVU, then enjoy being slow.

For me, I don't know if it's masochism or I'm busted, but I actually get a lot of enjoyment from burning and churning patients. Smashing the dispo is like little dopamine hits. Clearing that waiting room just feels good. There's no award for this. I don't feel special. I just can't help it and I don't like being not busy. The more pts I see, the faster it feels like Im back home.

If you still want to get fast, my tips are;
1. You shouldn't be in a room longer than 5 minutes at most. Most of the history is useless. Get good at tactfully cutting off patients and family. I usually start my PE when I'm ready for them to be done talking. Or sometimes I straight up say "let's focus on one problem today" or "what brought you in today specifically" etc.

2. Manage expectations. I let them know up front during hpi they're likely going home and I'm only ruling out life threatening illness and I rarely make a dx. This makes the follow up dispo significant faster.

3. I don't call family members. I don't call nursing homes. I don't call care givers. I see colleagues waste a huge amount of time on this. Zero gain.

4. Cancel the damn UA. 95% of the time you don't need it. If I truly need a UA. I bring the cup with me and say you get 30 minutes or you get a straight Cath. Or if they're some nursing home Jabba the hut dump then tell the nurses to auto Cath.

5. D dimer. Why? Do you really actually need this? I order 2-3 dimers a month. The slowest docs order this on almost every patient it seems like. Likely just comes from how people train. PERC them out or scan them or if it doesn't seem like a PE then do nothing.

6. Delta trop. Days or weeks of pain? Why get a second one. Don't delta trop to make a chart "look better".

7. Don't stagger orders. Don't be wishy-washy. Just be confident. If you think about it twice just order it. Tell nurses in the room you're going to need lactic, gas, ammonia or cultures up front. I usually even get the ice myself.

8. Nurses (and ancillary staff). It's shocking how many docs are dinguses to the staff. If you think this doesn't affect your workflow then you've already lost. This is arguably the most important point. The department doesn't revolve around us. Mean to the tech? Now you're getting all triage EKGs. Need that urine or repeat lab? Hope you were nice to the nurse. Just because you put a dispo in doesn't mean that's when they leave. They leave when the nurse feels like flipping the room. You routinely call CT asking where your CT is? Weird how I never ever have to do this. You're on everybody elses time. Not the other way around.

9. Consults. Why are you consulting? I hear colleagues all the time scramble to even come up with a reason on the phone on why they're calling someone and I experience severe secondhand embarrassment. Consults should be hey I have an appy. Hey acute chole. Hey head bleed. Hey I tried a,b,c, x,y,z without success now what. Don't call to ask permission to do things. Just put the chest tube in. Just cadiovert them. Don't call for follow up. Don't call to get a name in the chart. For the love of God stop calling for biliary colic-dc them

10. Admissions.. can write 100 pages on this. Direct correlation between slowest docs and inappropriate admissions. If you're always getting push back there is likely a reason. Really sit back and think if a patient actually needs admission.

11. Workup. Do they even need one? We do this with kids all the time. It's okay to discharge adults with doing nothing.

12. Don't sit on patients. I see this all the time. They're flagged ready for dispo and a doc will have like 3-5 of these just sitting there. If you're at your desk they should have dc ppwk printed within 60 seconds. Get them out.


And probably a lot more.

 

[emergentmd]

I was always #1 or #2 in my group for 15 years. I relinquished my #1 b/c a youngin wanted to make more money (we were 50% RVU) but stayed late 2 hrs to chart. I always went home when the doc came, maybe 30 min after they came, and typically spent my last 30 min of the shift getting coffee or just relaxing.

You should not aim to be the top, aim to be around 50-75% and get home when your shift ends. Bold is most imp. I spent the 1st year of my attending trying to figure out how to be efficient, see lots of patient, and also go home on time. My time is valuable and there are no point of being top when I have to have 2 hrs of work after my shift. I brought home 2 hrs of charting when I first started and was miserable.

My top 3

1. Pick up alot of pts at the beginning of your shift. I mean ALOT. We had non fast track ER so most had work ups. My place was busy so typically when I walked in, there were 5-10 pts to be seen in the rooms. I picked most if not all up and typically pick up 10 pts in the 1st hr. We did 8 hr shifts. So to achieve 2.5pph, I just needed another 10 pts in the next 7 hrs. Typically would pick up another 10 pts in the next 5 hrs. Last 2 yrs was to chart, dispo, get rid of them. Unless something easy came by or place was a wreck, I did not pick up anymore.

2. Order everything at once and rarely add on anything. I mean everything including imaging esp when you are going to do a CT anyhow. When everything is back, I dispo. So I get face time 2 times per pt typically.

3. Learn to game the charting system. There is always a way. I used dos based meditech which is prob the worse EMR. I could complete a really good chart in 2 minutes. I timed myself and was able to chart 25 pts in less than an hr on a busy shift. I did lots of copy/paste templates stored on the web. 95% of the pts fits into a template and I just change around age, date, when things started. I had about 200 templates with complete History, Physical, and MDM. That's right, when I figured out this game and every time I didn't have a template, I spent 10 min doing a new template.

I can add another 10 small things I do but these 3 will get you to 75% productivity and go home on time. Anything else I add just gives me extra time to get coffee or take my typicaly 5 breaks during my shift to walk to the doc lounge.

 

[Cognovi]

Does every peritonsillar abscess need a CT? Man, after you've seen enough of these, I can tell you exactly which ones are less than 2cm or over 2cm and which ones indicate the need for aspiration. I have no problem documenting that there is likely a developing tonsillar phlegmon but it is not large enough for drainage based on my clinical exam. No high risk features on exam. Put them on clinda/steroids and refer to ENT for f/u in 3 days. They absolutely do not need a CT with labs along with an 2 hour wait only for you to get back a 0.6cm abscess and your expected 12K WBC. Not to mention it took radiology 45 mins to convince the nurse to get an HCG before they would take her back for the imaging and now you've changed nothing about your disposition other than to ensure the pt is going to get triple their ER bill.

-your neighborhood neuroradiologist and otolaryngologist

 

[HemorrhagicShock]

As a fast doc all I can say is slow doc wins...unless you are getting paid solely on productivity, seeing fewer patients is easier for you snd you have less liability. One reason I quit my last job is that being fast isn't compensated or appreciated most places. Patients don't care, admin doesn't care, your colleagues appreciate it but that's not very important.

Stay slow and be happy.

This needs to be emphasized over and over and over and over again.

Read it a second time.

I've been top 3 in a fairly large group at a site that sees quite a few patients (95k/year) since finishing residency and all it's done for me is an occasional pat on the back by the director and massively added to my burnout. The turtles at the bottom of the list still have jobs, are still here, and I still don't know if they're blissfully ignorant of where they stand on the totem pole, or don't care (maybe it's a little of both).

When your colleague is sitting there chilling and you're killing yourself with that "sense of urgency" because literally 20+ checked in the last hour, that contempt builds up. It's not sustainable.

Be in the middle, or even just a little bit below, and realize that this is a marathon.

For what it's worth this is MUCH easier to say than it is to do for those of us who have been the "fastest." You have to learn this new form of zen, and effectively figure out a way for your brain to turn down the volume on that "sense of urgency." It's not easy, but it's necessary if you work at a place that isn't pure productivity.

 

[Mount Asclepius]

This discussion is totally influenced based upon how you are compensated. If based upon productivity, then speed matters. I also don’t think a race to the bottom creates a very healthy group culture or sustainable environment.

 

[thegenius]

All this emphasis on not working if on salary. I get it...but I don't get how that behavior is tolerated by admin for any length of time. If LWBS and patients complaints go up a lot, why wouldn't admin change it.

This situation occurred at the Kaiser I work at...and many years ago the system switched over to docs being assigned patients the moment a patient comes to the ER. It is a round robin assignment kind of thing.

Why see anybody at all, maybe see 5-8 patients per 8 hour shift if you are hourly?

 

[sloh]

This needs to be emphasized over and over and over and over again.

Read it a second time.

I've been top 3 in a fairly large group at a site that sees quite a few patients (95k/year) since finishing residency and all it's done for me is an occasional pat on the back by the director and massively added to my burnout. The turtles at the bottom of the list still have jobs, are still here, and I still don't know if they're blissfully ignorant of where they stand on the totem pole, or don't care (maybe it's a little of both).

When your colleague is sitting there chilling and you're killing yourself with that "sense of urgency" because literally 20+ checked in the last hour, that contempt builds up. It's not sustainable.

Be in the middle, or even just a little bit below, and realize that this is a marathon.

For what it's worth this is MUCH easier to say than it is to do for those of us who have been the "fastest." You have to learn this new form of zen, and effectively figure out a way for your brain to turn down the volume on that "sense of urgency." It's not easy, but it's necessary if you work at a place that isn't pure productivity.

What do you do when you're bored out of your mind on shift?

 

[emergentmd]

Why see anybody at all, maybe see 5-8 patients per 8 hour shift if you are hourly?

Unless there is accountability, there isn't. Some will chose to see more bc its the right thin to do. Some will not no matter what.

What do you do when you're bored out of your mind on shift?

The doc lounge, check email, do some SDN, cafeteria....

 

[miacomet]

This needs to be emphasized over and over and over and over again.

Read it a second time.

I've been top 3 in a fairly large group at a site that sees quite a few patients (95k/year) since finishing residency and all it's done for me is an occasional pat on the back by the director and massively added to my burnout. The turtles at the bottom of the list still have jobs, are still here, and I still don't know if they're blissfully ignorant of where they stand on the totem pole, or don't care (maybe it's a little of both).

When your colleague is sitting there chilling and you're killing yourself with that "sense of urgency" because literally 20+ checked in the last hour, that contempt builds up. It's not sustainable.

Be in the middle, or even just a little bit below, and realize that this is a marathon.

For what it's worth this is MUCH easier to say than it is to do for those of us who have been the "fastest." You have to learn this new form of zen, and effectively figure out a way for your brain to turn down the volume on that "sense of urgency." It's not easy, but it's necessary if you work at a place that isn't pure productivity.

Agreed. Very few jobs compensate adequately for hard work, IME most overcompensate for patient (and nurse) satisfaction, and the slow, stupid docs are always seen as "nice" and are quickly promoted to CMO/director etc, while the efficient, effective clinicians are left to run the pit, and not compensated for it.
If I were a slow doc, I might be working at my previous places of employ, but it's hard doing everyone else's work for them and not getting compensated. Like most things in life, stupid, slow or lazy people win, and hardworking, smart people are punished.

 

[EctopicFetus]

Several things:

1.) ABC&D: Always Be Charting & Dispoing
2.) Find the rate limiting step for each patient that will lead to a disposition and make sure it gets done quickly.
3.) Picking up the sick and complicated patients are honestly sometimes the easiest patients as you already know their disposition (admission).
4.) Put all your orders in correctly at the beginning. Don't get some labs, get the results, get some more labs, then order some imaging, etc.

All of
This. I’m one of the fastest in my group and was in my old
Group. If anything ask one of the fast docs to shadow them for a bit to learn their tips and tricks.

I find scribes doing charts relieves a ton of mental space for me. I also put in all my orders at once. Also depending on where you work put in orders before they come back.

Read the triage note. Chest pain NOS 85 year old. Put the orders in. Ankle sprain. Put the orders in. Etc.

I can put the totally correct orders in on 75-80% of my patients with a decent triage note.

As stated above. ABCD.

 

[emergentmd]

got some colleagues that go bonkers over peri-arrest semi-codes that dump into the ER.

Yeah they were fun in residency to learn but just like Joint reduction, lacerations, minor procedures after about 10; A good shift is if I don't do one. Have at the CPR, Central line, Cooling protocol, pressors and lost hour if you like.

Do all these patients need labs?

For real. I see partners do Labs on pedi pts all the time. I would say I do labs in 1/50 pedi pts. Really, is anything going to change other than torture.

Do they need that 2nd and 3rd troponin

I prob do 2 trop in 1/10 pts. If I am going to admit no matter what, no need for a 2nd. If I know I am going to d/c then no need for a 2nd.

Does every peritonsillar abscess need a CT?

If you think its an abscess, then Just drain and send home. Another unnecessary tests unless I am not sure. I mean if nothing is there to drain, a CT showing a small abscess is not changing much

Don't fear the waiting room. Stop sitting in a chair and being lazy. Take a COW/WOW out there and start dumping in MSE orders or pulling people into cubby's to get a brief history or exam. When our ED is gridlocked, I immediately go out to the waiting room and see people in this manner.

I will disagree here. Its a no go for me. I am not giving admin an excuse for understaffing, not getting the hospitalists act together, not getting rad support. I am not fixing their flow issues.


.

 

[Janders]

Lots of great advice

I disagree here:
“Does your nursing home pt coming in for PEG tube change even need an XR? And even if you get the gastrograffin XR, do you even need the radiologist to read it befog you d/c them back home? Of course not.”

Get the gastrograffin X-ray to prove you tube is in. Order it portable. When you see them wheeling the machine towards to room, run over and squirt in the gastro. Look at the picture. BEAUTIFUL STOMACH. Bask in the glow of the admiration of the Radiology Tech. Walk back to your computer and click dispo.

I say this b/c I’m aware of a couple cases of “easy” G-tube replacement that went into subQ tracts or in the peritoneum, with a couple resulting in death.

You don’t need to be waiting for radiology to read it… that might be 16hr later.

 

[emergentmd]

Lots of great advice

I disagree here:
“Does your nursing home pt coming in for PEG tube change even need an XR? And even if you get the gastrograffin XR, do you even need the radiologist to read it befog you d/c them back home? Of course not.”

Get the gastrograffin X-ray to prove you tube is in. Order it portable. When you see them wheeling the machine towards to room, run over and squirt in the gastro. Look at the picture. BEAUTIFUL STOMACH. Bask in the glow of the admiration of the Radiology Tech. Walk back to your computer and click dispo.

I say this b/c I’m aware of a couple cases of “easy” G-tube replacement that went into subQ tracts or in the peritoneum, with a couple resulting in death.

You don’t need to be waiting for radiology to read it… that might be 16hr later.

Yeah I agree. Never am I sending someone with new PEG tube without an Xray with radiology overread. I have seen some go in the wrong place, misread by the Er doc, and they get sick. I will "cut" corners, but this is not one.

 

[Janders]

Yeah I agree. Never am I sending someone with new PEG tube without an Xray with radiology overread. I have seen some go in the wrong place, misread by the Er doc, and they get sick. I will "cut" corners, but this is not one.

I’ve seen one that was hard to pass in an obese person, but eventually slid in and inflated well… where the stomach opacified w/ contrast but on rads detailed read the ballon was NOT in the stomach, just the very tip of the tube. That was a bit more subtle than the couple I know of where no X-ray was taken b/c it was a mature tracks and they fed the peritoneal cavity for a day or two.

 

[CoolDoc1729]

Or more specifically, increasing PPH?

I've dug through our data and I am in the bottom third at best in terms of PPH. My level 5 charts and CC billing are above group average but overall RVU/hour is average to slightly Below. Now, perhaps I'm just intentionally picking complicated and sick people, but I doubt it. Or my partners are cherry picking all day every day and I just haven't noticed.

So, who can point me to good resources for how to pick up the pace?

Resources? Nah. I’m always in the top two for pph, rvu/h- we get a spreadsheet every month. I’m not as fast as some who always have lower numbers. Part of that is I don’t allow the mid levels to keep ESI 2-3, I take them over basically using the mid level as a scribe, if they don’t like it too bad, I don’t like them mismanaging sick people. Part is that we are inadequately staffed on nights because “no one comes in” 🙄 ignoring the fact I have to basically end up seeing everyone who gets there on my shift plus most of the people who came in 4-6 hours before I started for dispo.

Are there patients to pick up and you don’t? Are you rvu based and everyone’s hungry where you work ? Do you order a second round of tests on more than 1 patient per shift prior to dispo? Do you work your waiting room? All these will help pinpoint where you can pick up PPH.

Though as others point out it’s also adding liability and you can’t rush all the time at work for 10-20 years, it’s not sustainable.

 

[JacobMcCandles]

I’ve seen one that was hard to pass in an obese person, but eventually slid in and inflated well… where the stomach opacified w/ contrast but on rads detailed read the ballon was NOT in the stomach, just the very tip of the tube. That was a bit more subtle than the couple I know of where no X-ray was taken b/c it was a mature tracks and they fed the peritoneal cavity for a day or two.

Sounds like they need to cut down on the tube feeds to regulate their weight a bit better. Or they're taking PO just fine and don't need the G-tube.

 

[JacobMcCandles]

Where I am, if the nursing home sends you a patient then you're going to be waiting a minimum of 4 hours to arrange transport to take them back. They're currently a throughput killer.

 

[WorkNoteEmergency]

OP, everyone has their own style but as you can see there is some commonality in the work flow of the higher productivity docs. Parallel instead of linear workups (example - I don't use d-dimer very much PERC neg or straight to CT, ED stay reduced by 1 hour.) In my first couple of years out I was similar to you in that my PPH was average for the group but I had higher acuity patients. I worked in a high volume, high acuity ER with a lot of docs working at once. Almost always at least a couple patients waiting to be seen. I would pick the higher acuity patients, reasoning that they need to be seen faster. We had a bit of a cherry picking problem in the group, so we mandated that patients be seen in the order they come into treatment area unless obviously critically ill. My PPH jumped once I started doing this.

Another means is use shift modeling, especially useful if you're in a shop with multiple docs and overlapping shifts. Aim for 3-4 PPH for first 2-3 hours, chart where you can but put off for later if needed, 2/hr for middle portion, taper off for last 1-2 hrs and concentrate on tidying up and finishing charts. End of shift if not too busy, then pluck some easy ones out of the WR.

I used to be gung ho and took pride in cleaning up the ER and WR but don't apply this much any more and my only interest in any productivity now is to avoid screwing over my partners, a trait I think many of us share and taken advantage of by admin. I still have one of lowest LOS and admin % in the group.

 

[GonnaBeADoc2222]

Great advice above.

Similarly, I was always a hustler.

Figured out that in my non RVU ponzi scheme shop, old timers be making 100k more than me to see less or equal number of patients.

Since then, I have throttled back my productivity, chill for majority of my shift, yet still am in the top 5. Mind boggling.

There are no repercussions for the slows aside from getting a suggestion from admin that they should not be slow. Similarly, there is no reward for being fast, so why be fast?

 

[Dr Mantis Toboggan]

Where I am, if the nursing home sends you a patient then you're going to be waiting a minimum of 4 hours to arrange transport to take them back. They're currently a throughput killer.

Yup it’s brutal.

 

[EctopicFetus]

Great advice above.

Similarly, I was always a hustler.

Figured out that in my non RVU ponzi scheme shop, old timers be making 100k more than me to see less or equal number of patients.

Since then, I have throttled back my productivity, chill for majority of my shift, yet still am in the top 5. Mind boggling.

There are no repercussions for the slows aside from getting a suggestion from admin that they should not be slow. Similarly, there is no reward for being fast, so why be fast?

Depends on the model. I’m 100% rvu. Plenty of incentive to be fast. Otherwise work a comfortable pace. Truly to you hourly guys what’s the reason to push the system. I would probably be fairly passive if I was an employed doc or cmg doc.

 

[GonnaBeADoc2222]

The thing they don't get is....you can force retirement on these boomers by saying "hey we're gonna cut your pay 100k, take it or leave it" and then hire thirsty new grad docs for what I make, who will be energetic and see lots of patients.

How do they not see this?

 

[BoardingDoc]

The thing they don't get is....you can force retirement on these boomers by saying "hey we're gonna cut your pay 100k, take it or leave it" and then hire thirsty new grad docs for what I make, who will be energetic and see lots of patients.

How do they not see this?

The benefit of a pure productivity model. Hungry docs work harder, make more. If you want to throttle back, you can. You just get paid based on how hard you work. You never need to worry about these compensation imbalances because the scale constantly balances itself.